Families express anger that hospital did not act on mistakes

Last week, the Commission for Health Improvement said that St Peter’s had learnt all lessons from obstetric disasters that have hit unit in the past years. Here, those most affected by the tragedies give their reaction

A WELCOME tempered by caution and scepticism was this week given to the findings of the latest inquiry into St Peter’s Hospital maternity unit by the families who have lost children there.

The bereaved parents called for evidence that the recommendations of the Commission for Health Improvement (CHI) had been implemented and demanded plans for a long term review of pratices at the notorious unit.

Last week the CHI released its report which found that key recommendations from health authorities and internal inquiries had not been implemented.

The independent investigators, who scrutinised incidents at the unit between January 2000 and June 2002, announced that consultants were at loggerheads – a situation the CHI felt could put lives in danger.

The CHI has strongly recommended that the lack of consultant presence on the labour ward must be addressed.

It has also asked the management at the hospital to begin a thorough examination of junior doctor training.

Liz Fradd, the CHI’s director of nursing said in announcing the report’s findings that they had “serious concerns” about some aspects of the unit.

She added: “We felt the trust had not learnt all the lessons from the incidents where babies had died.”

Cautious

A cautious welcome was given to the findings by Lisa Hough whose son was stillborn at St Peter’s.

Lisa and her husband Martin had to fight for an independent review into the death of Conor Hough at the unit in 1998 — a battle his mother said they have continued to save other families similar heart ache.

However, the Hough’s case was not the last at St Peter’s which stemmed from failings which were highlighted in the CHI report published last week.

“When I was received at St Peter’s I was seen by the consultant having been referred by another consultant and then seen by a registrar.

“I did not think that they looked at the things that mattered to me and there did not seem to be a great deal of communication there.”

Lisa was sent to the Chertsey unit from Frimley Park in an ambulance because she needed a caesarean, which could have resulted in her baby needing specialist care at St Peter’s.

“The independent review highlighted the poor levels of communication and recommended that something be done,” she explained.

“We had to fight for our independent inquiry, having to finally use a solicitor.

“I think its disgraceful that it took us three years and it has been made worse by the fact that the situation has not improved.

“The reason we kept on going was to try and make sure it didn’t happen to someone else’s baby.”

The deaths of Chloe Jade Freeman and Hollie Dinning took place at the maternity unit before the CHI stepped in.

Lisa said: “I hope this latest report will have an impact but given my own past experiences it does not bode well.

Cathy Rowbourne was also pessimistic that the hospital was capable of implementing real change.

She told the News & Mail: “We said from the very beginning that the stillbirth of our son Joshua was not just an unlucky incident for us, but a systemic failure.

“The management of St Peter’s Hospital have refused to take that on board even though Phillip and I have had to watch numerous other families go through the horrific and needless ordeal that we did.

“We believe that things will only change when people are held properly accountable.

“The CHI report recommendations bear a striking resemblance to reports into the death of our son, but the doctors remain working at the hospital. Nobody has been punished.”

Her comments were echoed by David Donaldson, father of Luke who was catastrophically brain damaged during his birth. St Peter’s have admitted liability.

Luke is six-years-old now and needs constant care. David says he has not progressed much since his birth, but is more comfortable than in the immediate aftermath when he suffered from 50 or 60 fits a day.

Profound damage

“Luke was so profoundly damaged by the birth, but we have managed to improve his quality of life,” he told the News & Mail.

“That is all we can hope for. He no longers screams all day.

“We have a daughter now. She is lovely. But we now can see exactly what Luke has missed and we can’t help wondering what he might have been.

It’s difficult. Luke can’t give much back. Sometimes, if we are lucky, we get a smile.

“They let Luke down but it appears that nobody has been punished for what happened. We were told after his birth that this was a one off — that they would learn from what had happened and make sure it never happened again.

“They obviously did not and carried on the way they were. They must have just thrown his notes in the cupboard.

“And even now they are saying that the training for doctors in reading heart monitors needs to be improved and the consultants should be on the ward more.”

Monitoring

All the parents said they believed that rigourous monitoring needed to be in place to make sure that the recommendations were implemented and adhered to.

Rosie Newbigging, who led the CHI’s investigation into the Chertsey unit, assured the News & Mail that the trust would have to be seen to be taking action following the report.

Ashford and St Peter’s Hospitals Trust will be expected to come up with an action plan, in conjunction with Surrey and Sussex Strategic Health Authority aimed at implementing the CHI’s 36 recommendations.

“Over the next couple of months the CHI will expect to see a draft action plan being drawn up between Ashford and St Peter’s Trust and the strategic health authority,” she said.

“The CHI will be involved in this as we want to have a day with the trust, the local primary care trusts, strategic health authority, and the community health councils to go through the recommendations in the report.”

She added that this will eventually result in an action plan which will be published on the CHI’s website.